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News 11/9/18

November 8, 2018 News 1 Comment

Top News

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Google will hire Geisinger President and CEO David Feinberg, MD, MBA to develop its healthcare strategy across its business units that include search, cloud, AI, Nest home automation, and Google Fit wearables. 

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Reader Comments

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From Keeping It Real: “Re: NextGen blog post. I guess you get what you pay for in marketing and social advisors since someone was apparently OK with citing a competitor’s opinion piece.” I’m puzzled by the blog post that is attributed to NextGen Healthcare CMIO Robert Murry, MD since it not only cites a blog post of competitor Nextech, the Nextech post is hardly original (a “free” EHR may involve paid add-ons that make it more expensive than a paid system, it basically says). I’m pretty sure this was ghost-written by a NextGen marketing person since Bob has outstanding education and experience (not to mention his esteemed credential as a member of Dann’s HIStalk Fan Club on LinkedIn) and I doubt he’s looking to Nextech for inspiration. I’ll also say that I get puff pieces every day that are supposedly written by vendor C-level executives that clearly were hacked together by a marketing committee who took a quick, “OK, fine, whatever” response from the alleged author as meaning they did great when they clearly did not. 

From Smallie Biggs: “Re: LinkedIn. Is it creepy when people write their entries in the third person or call themselves ‘Mr.’ or ‘Ms.’ in describing how wonderful they are? Absolutely. Stiffly written LinkedIn profiles make me question whether that person has an ounce of creativity or originality in them, and if they applied to work for me, I would be instantly prejudiced into moving on to someone who seems more human.


HIStalk Announcements and Requests

Listening: a good protest song and video from rapper Kap G (whose music I generally dislike) called “A Day Without a Mexican.” Kap G (real name: George Ramirez) proudly wears his Mexican lineage (literally) despite rather light cred given that he was born and raised in College Park, GA. I’m also really, really liking Spain-based Mägo de Oz (Spanish for “Wizard of Oz” with the mandatory metal umlaut thrown in because they have a sense of humor),  which deftly plays an amalgam of heavy metal, Celtic, and 1980s-style power rock, kind of like Iron Maiden, Asia, and Jethro Tull co-creating a Spanish-language metal opera from “Lords of the Dance.” They’re big in a lot of places that aren’t here.


Webinars

None scheduled soon. Previous webinars are on our YouTube channel. Contact Lorre for information.


Acquisitions, Funding, Business, and Stock

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Bedside patient engagement company GetWellNetwork acquires HealthLoop, a Silicon Valley-based developer of automated messaging for follow-up care. Terms of the deal were not disclosed. HealthLoop, which has raised $22 million since launching in 2009, will work with GetWellNetwork to develop an integrated solution called GetWell Loop in the coming months.

Medication safety technology vendor Tabula Rasa HealthCare acquires Cognify, which offers solutions to support the federal PACE (Program of All-inclusive Care for the Elderly) program.


Sales

  • ClinicalConnect HIE (PA) selects Fusion, Analyze, and Quality apps from Diameter Health to automate and standardize data exchange.
  • Charleston Area Medical Center (WV), Fairview Health Services (MN), and University of Minnesota Physicians select release-of-information services from MRO.
  • Pacific Dental Services, which provides back-office services for dental practices, will implement Epic to allow practices to coordinate with other clinicians.

People

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Michael Johnson (Community Health Systems) joins Medhost as CISO.

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Greenway Health promotes Kimberly O’Loughlin to president.

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Chief Health Information Officer Neal Patel, MD, MPH will replace Chief Informatics Officer Kevin Johnson, MD, MS as head of health IT efforts at Vanderbilt University Medical Center (TN) as of January 1. Johnson will retain his position as chair of Vanderbilt University School of Medicine’s Department of Biomedical Informatics. Both men oversaw the hospital’s two-year Epic implementation and optimization efforts.

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Anne Hunt (Castlight Health) joins healthcare messaging vendor Medici as VP and head of product following its acquisition of DocbookMD.

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PatientKeeper names Barry Gutwillig (Kofax) VP of sales and marketing.

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Jeff Miller (The SSI Group) joins AMA-backed Akiri as COO.

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Jennifer LeMieux (JRMH Consulting) returns to healthcare consulting and hospital management company HealthTechS3 as COO.

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Audacious Inquiry names Keith “Motorcycle Guy” Boone (GE Healthcare) as informatics adept. I had to look that word “adept” up and I like it – it can be used as either an adjective or noun to describe someone who is skilled in a particular area.

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HealthStream promotes Trisha Coady to SVP/GM of clinical solutions.

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Peter Siavelis (StayWell) joins Waystar as SVP of health systems.

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Industry long-timer Brian Graves (Concentra Analytics) joins Hospital IQ as VP.


Announcements and Implementations

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Novant Health (NC) goes live on Glytec’s EGlycemic Management System.

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Cedar County Memorial Hospital (MO) goes live on Meditech Expanse with consulting help from Engage.

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Physicians at Upstate University Hospital (NY) develop a training program using Vocera’s Rounds mobile app to capture data about hospitalist behavior during patient interactions and to provide real-time feedback.

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In Maine, the ACO of Northern Light Health (just renamed from Eastern Maine Healthcare Systems, which was oddly pluralized, and not to be confused with Northern Lights Regional Healthcare Centre in Alberta, Canada) adopts PatientPing’s real-time admit-discharge-transfer notification services. The name change creates an awkward title for the flagship hospital, “Northern Light Eastern Maine Medical Center,” which I’m guessing basically nobody will use in favor of the perfectly serviceable old name of Eastern Maine Medical Center or EMMC.


Government and Politics

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After a pilot study with Kaiser Permanente, the FDA releases the open-source code behind its new MyStudies app. The app was developed to give patients, providers, and developers an easier way to report and collect health data that can then be used to inform the development of drug and medical devices, and patient safety efforts.


Other

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Hawaii Pacific Health VP Melinda Ashton, MD describes the origin and progress of the health system’s “Getting Rid of Stupid Stuff” program, which aims to streamline EHR workflows based on nursing and physician requests. Since launching in October 2017, requests have been submitted and acted on in three main categories – documentation that was never meant to occur, documentation that could be done more effectively, and required documentation that end users didn’t fully understand. Ashton says, “When the campaign was unveiled, it was largely met with surprise and sheepish laughter, then applause. We seem to have struck a nerve. It appears that there is stupid stuff all around us, and although many of the nominations we receive aren’t for big changes, the small wins that come from acknowledging and improving our daily work do matter.”

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Mid Atlantic Permanente Medical Group cardiologist and Epic user Ameya Kulkarni, MD posts a thread of tweets reacting to Atul Gawande’s New Yorker piece on the contempt physicians have for their computers, noting more than once that the EHR is not the biggest contributing factor to physician burnout. “To fight burnout,” he says, “we need to think about how our communication systems increase loneliness and reduce agency. These are the key drivers. … And working on loneliness means 1) creating opportunities for real world interaction with colleagues and patients & 2) Simplifying documentation requirements so notes become communication tools again.”

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A study of the EHR experience of medical students in Australia finds that they have no problems learning it, using it, or understanding its advantages. They also don’t feel that using the EHR detracts from patient interaction or rapport. They do, however, say that the EHR doesn’t help them learn as much as they expected.


Sponsor Updates

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  • HCTec staff volunteer at Hope Lodge, an organization in Nashville helping those undergoing cancer treatments.
  • AdvancedMD employees pack over 900 weekend pantry packs for students in the Granite School District.
  • Agfa Healthcare partners with PACSHealth to implement system-wide radiation dose monitoring at the Veterans Integrated Service Networks 19.
  • Apixio will exhibit at RISE: The 12th Risk Adjustment Forum November 11-13 in Marco Island, FL.
  • Aprima publishes a new guide, “How to Switch EHRs.”
  • Over 50 Florida hospitals now receive data through state-based HIE services, including Audacious Inquiry’s Encounter Notification Service.
  • Bluetree will exhibit at the RCM Leaders Forum November 14-16 in Dallas.
  • CenTrak publishes a new customer testimonial featuring Diane Drefcinski from the University of Wisconsin.
  • ChartLogic publishes a new white paper, “How to Prepare for MIPS in 2019.”
  • CompuGroup Medical will exhibit at the AZ HIMSS Tucson Education Event November 15.
  • CoverMyMeds will exhibit at the ECRM pharmacy technology event November 12-14 in Cape Coral, FL.
  • Diameter Health will exhibit at the NCQA HL7 Digital Quality Summit November 14-15 in Washington, DC.
  • Docent Health is mentioned in a new book on healthcare consumerism, “Choice Matters: How Healthcare Consumers Make Decisions (and Why Clinicians and Managers Should Care).
  • DocuTap will accept submissions for its scholarship program through December 2.
  • Elsevier will integrate the National Comprehensive Cancer Network’s Clinical Practice Guidelines in Oncology with its Via Oncology clinical decision support tool.
  • EClinicalWorks will exhibit at the 2018 NNOHA Annual Conference November 12-13 in New Orleans.
  • EPSi will exhibit at the HFMA Region 9 Conference November 11-13 in New Orleans.
  • FormFast will exhibit at the GC3 Conference November 14-16 in Mobile, AL.
  • Spok notes that it has been ranked #1 by Black Book for secure communications in hospitals.
  • Healthwise and Imprivata will exhibit at NextGen UGM 2018 November 11-14 in Nashville.
  • Imat Solutions will exhibit at the TAHP 2018 Managed Care Conference and Trade Show November 12-14 in Houston.
  • Iatric Systems will exhibit at HCCA Regional November 16 in Nashville.
  • Influence Health congratulates four renowned health system customers for their 2018 MarCom Awards.
  • Black Book Market Research ranks Spok number one in secure communications for hospital systems.
  • Divurgent hires Robert Leahey (Axiom Systems) as principal.
  • Piedmont Healthcare (GA) improves clinical documentation and physician productivity with Nuance’s AI-powered solutions.
  • Meditech releases a new podcast on EHR value and sustainability.

Blog Posts


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Contacts

Mr. H, Lorre, Jenn, Dr. Jayne.
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EPtalk by Dr. Jayne 11/8/18

November 8, 2018 Dr. Jayne 1 Comment

There was some chatter in the physician lounge this week about a study published in JAMA Network Open looking at the accuracy of EHR medication lists vs. the substances actually found in patients’ blood. Researchers looked at 1,350 patients and found that while a majority of medications were detected in the blood as listed in the EHR, there were many more medications detected that were not reflected in the EHR. Such incomplete documentation prevents systems from performing drug-allergy and drug-drug checking, placing patients at risk.

As much as some clinicians don’t like it, I prefer when patients bring in all their medications and supplements, even if it takes extra time going through a brown bag, shoebox, or tote. That way we can keep the EHR updated and also physically impound medications that patients shouldn’t be taking, if warranted.

There was also a fair amount of conversation around Tuesday’s elections, and the various positions held by candidates regarding healthcare. Kaiser Health News published a great piece looking at the various terms being thrown around during the election, including single-payer, universal healthcare, and Medicare for all. Gubernatorial candidates in California, Massachusetts, and Florida were pushing for state-run single-payer systems, where others were calling for less specific “universal coverage” or “public option” provisions. Like those mentioned in the article, the physicians around my lunch table didn’t fully understand the different models or what they might mean not only to their practices, but to their families.

There was zero chatter around the announcement by CMS that access to Quality and Resource User Reports and PQRS Feedback Reports will be sunset at the end of December. Since 2016 was the last performance period for those programs and 2018 was the final payment adjustment year, there isn’t much of a need for the reports to remain online. Physicians or their authorized representatives can download them until December 31, but it’s unclear how many providers reviewed the data in the first place or whether they tried to use it to drive practice-level improvements. Reports will be available eon the CMS portal for those of you looking for a little bedtime reading.

As I was getting ready to leave, one of my colleagues asked me what I thought of Atul Gawande’s recent New Yorker essay on “Why Doctors Hate Their Computers.” He takes readers through Partners HealthCare’s journey from homegrown EHR to Epic, and all of the physicians around the table were familiar with that 16 hours of training he leads with. (In our case, it was 17, and let me tell you everyone was counting.)

Having run more than a handful of EHR implementation projects, I loved Gawande’s description of his trainer, “younger than any of us, maybe a few years out of college, with an early-Justin Bieber wave cut” whose technique incorporated “the driver’s ed approach: You don’t want to be here; I don’t want to be here; let’s just make the best of it.”

Gawande walks us through his own thoughts about the rise of computers, including the once-coveted Commodore 64, which brings back memories for some of us who have been on the cutting edge. Having been the second person I knew with a modem (the first being the guy from whom my brother bought the used card from), I felt a little bit of his pride and optimism as he readied himself for training. The last three years have quashed that optimism, however, and he has “come to feel that a system that promised to increase my mastery over my work has, instead, increased work’s mastery over me.”

I appreciated his discussion of “the Revenge of the Ancillaries,” where design choices were considered by constituents from various parts of the organization. He makes a point that was telling: “The design choices were more political than technical: administrative staff and doctors had different views about what should be included. The doctors were used to having all the votes… Now the staff had a say (and sometimes the doctors didn’t even show.)”

I’ve seen that happen during several build decision projects, and it sounds like there may not have been adequate checks and balances in the governance process. For example, requiring stakeholder signoff in addition to participation in the working groups. Requiring user acceptance testing of critical workflows would also have caught some of the issues he cited, such as hard stops and required fields, prior to the go-live. He also highlights issues with the maintenance of patient problem lists that are exacerbated by governance issues, with duplications and lack of specificity in entries. Cut and paste is also an issue, one that could be addressed by governance and consensus among users about the best way to use the EHR.

Gawande does discuss the phenomenon of governance, noting that, “As a program adapts and serves more people and more functions, it naturally requires tighter regulation. Software systems govern how we interact as groups, and that makes them unavoidably bureaucratic in nature. There will always be those who want to maintain the system and those who want to push the system’s boundaries.”

I’m in agreement, but it’s still a challenge to figure out why organizations don’t spend the time needed up front to define some of these goals. What is the vision for the new system? How does it support the mission? What are the expected outcomes? How do we define success? Instead it’s often a race against a timeline, which may or may not reflect organizational tolerance for a particular speed of change. The best implementation I ever worked on had a motto of “go slow to go fast.” We may have spent more months in the design and build phase than other organizations, but when we went live, we hit the ground running and there were very few changes needed to the system in the first few months.

Mr. H has already commented on the Gawande piece, and one reader shared their thoughts on the physician mentioned who admittedly ignores messages in her inbox and deletes them without reading them. I hope there aren’t any patients reading The New Yorker who might have a concern about their care in her practice, because if she is ever called into court about a missed diagnosis, things aren’t going to end well for her. I can’t imagine publicly admitting that I don’t review results and I doubt that the medical staff administration is going to think too kindly of it.

Reading the piece from the perspective of a clinical informaticist, there’s a lot to unpack, and also a lot of opportunity to potentially improve things for the impacted physicians. I’m not sure what I think about it from a patient perspective or a non-IT perspective, since it oversimplifies and under-explains some of the complexities that have brought us to where we are. That’s what I told my colleague, and I ended with a reminder that the one of the EHR subcommittees still has some openings, so if he wants to be part of the solution, there’s a venue available.

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I don’t frequently call out companies for wacky marketing, but this one is baffling. The subject line of the email advertises a profitability webinar with “cybersecurity strategies you can use,” but the email itself discusses patient experience and how to “cultivate a loyal base.” Oh yeah, and there’s the part where they sent the invitation out less than 24 hours in advance for a webinar that is in the middle of the work day. For mass marketing emails, I’d recommend peer review at a minimum before sending them out. Get it together, folks.

[UPDATE] Greenway Health was quick to read Dr. Jayne’s comment and apologize that their email preview line displayed incorrect wording (the subject line itself was correct). They also note that this was the third in a three-email series, so those who wanted to sign up had ample time well before this email. They also say their surveys and best practices indicate that 2:00 p.m. ET works best for providers.

Do cold emails entice you to join webinars in the middle of the day? How many do you register for that you end up not attending? Leave a comment or email me.

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Email Dr. Jayne.

Morning Headlines 11/8/18

November 7, 2018 Headlines No Comments

Focused on Customer Success, Greenway Health Announces the Appointment of Kimberly O’Loughlin to President

After six months with the company as COO, Greenway Health promotes Kimberly O’Loughlin to president.

FDA launches new digital tool to help capture real world data from patients to help inform regulatory decision-making

The FDA will use data collected directly from patients through its new open-source MyStudies app to inform future drug development and medication and device safety efforts.

Mobile Telehealth Company Medici Acquires DocbookMD

Healthcare messaging and virtual visit company Medici acquires competitor DocbookMD from Scrypts for an undisclosed amount.

A Machine Learning Primer for Clinicians–Part 4

Alexander Scarlat, MD is a physician and data scientist, board-certified in anesthesiology with a degree in computer sciences. He has a keen interest in machine learning applications in healthcare. He welcomes feedback on this series at drscarlat@gmail.com.

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Previous articles:

  1. An Introduction to Machine Learning
  2. Supervised Learning
  3. Unsupervised Learning

How to Properly Feed Data to a ML Model

While in the previous articles I’ve tried to give you an idea about what AI / ML models can do for us, in this article, I’ll sketch what we must do for the machines before asking them to perform magic. Specifically, the data preparation before it can be fed into a ML model. 

For the moment, assume the raw data is arranged in a table with samples as rows and features as columns. These raw features / columns may contain free text; categorical text; discrete data such as ethnicity; integers like heart rate, floating point numbers like 12.58 as well as ICD, DRG, CPT codes; images; voice recordings; videos; waveforms, etc.

What are the dietary restrictions of an artificial intelligence agent? ML models love their diet to consist of only floating point numbers, preferably small values, centered and scaled /normalized around their means +/- their standard deviations.

No Relational Data

If we have a relational database management system (RDBMS),  we must first flatten the one-to-many relationships and summarize them, so one sample or instance fed into the model is truly a good representative summary of that instance. For example, one patient may have many hemoglobin lab results, so we need to decide what to feed the ML model — the minimum Hb, maximum, Hb averaged daily, only abnormal Hb results, number of abnormal results per day? 

No Missing Values

There can be no missing values, as it is similar to swallowing air while eating. 0 and n/a are not considered missing values. Null is definitely a missing value.

The most common methods of imputing missing values are:

  • Numbers – the mean, median, 0, etc.
  • Categorical data – the most frequent value, n/a or 0

No Text

We all know by now that the genetic code is made of raw text with only four letters (A,C,T,G). Before you run to feed your ML model some raw DNA data and ask it questions about the meaning of life, remember that one cannot feed a ML model raw text. Not unless you want to see an AI entity burp and barf.

There are various methods to transform words or characters into numbers. All of them start with a process of tokenization, in which a larger unit of language is broken into smaller tokens. Usually it suffices to break a document into words and stop there:

  • Document into sentences.
  • Sentence into words.
  • Sentence into n-grams, word structures that try to maintain the same semantic meaning (three-word n-grams will assume that chronic atrial fibrillation, atrial chronic fibrillation, fibrillation atrial chronic are all the same concept).
  • Words into characters.

Once the text is tokenized, there are two main approaches of text-to-numbers transformations so text will become more palatable to the ML model: 

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One Hot Encode (right side of the above figure)

Using a dictionary of the 20,000 most commonly used words in the English language, we create a large table with 20,000 columns. Each word becomes a row of 20,000 columns. The word “cat” in the above figure is encoded as: 0,1,0,0,…. 20,000 columns, all 0’s except one column with 1. One Hot Encoder – as only one column gets the 1, all the others get 0.

This a widely used, simple transformation which has several limitations: 

  • The table created will be mostly sparse, as most of the values will be 0 across a row. Sparse tables with high dimensionality (20,000) have their own issues, which may cause a severe indigestion to a ML model, named the Curse of Dimensionality (see below).
  • In addition, one cannot represent the order of the words in a sentence with a One Hot Encoder.
  • In many cases, such as sentiment analysis of a document, it seems the order of the words doesn’t really matter.

Words like “superb,” “perfectly” vs. “awful,” “horrible” pretty much give away the document sentiment, disregarding where exactly in the document they actually appear.

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From “Does sentiment analysis work? A tidy analysis of Yelp reviews” by David Robinson.

On the other hand, one can think about a medical document in which a term is negated, such as “no signs of meningitis.” In a model where the order of the words is not important, one can foresee a problem with the algorithm not truly understanding the meaning of the negation at the beginning of the sentence. 

The semantic relationship between the words mother-father, king-queen, France-Paris, and Starbucks-coffee will be missed by such an encoding process.

Plurals such as child-children will be missed by the One Hot Encoder and will be considered as unrelated terms.

Word Embedding / Vectorization

A different approach is to encode words into multi-dimensional arrays of floating point numbers (tensors) that are either learned on the fly for a specific job or using an existing pre-trained model such as word2vec, which is offered by Google and trained mostly on Google news. 

Basically a ML model will try to figure the best word vectors — as related to a specific context — and then encode the data to tensors (numbers) in many dimensions so another model may use it down the pipeline.

This approach does not use a fixed dictionary with the top 20,000 most-used words in the English language. It will learn the vectors from the specific context of the documents being fed and create its own multi-dimensional tensors “dictionary.” 

An Argentinian start-up generates legal papers without lawyers and suggests a ruling, which in 33 out of 33 cases has been accepted by a human judge.

Word vectorization is context sensitive. A great set of vectorized legal words (like the Argentinian start-up may have used) will fail when presented with medical terms and vice versa.

In the figure above, I’ve used many colors, instead of 0 and 1, in each cell of the word embedding example to give an idea about 256 dimensions and their capability to store information in a much denser format. Please do not try to feed colors directly to a ML model as it may void your warranty.

Consider an example where words are vectors in two dimensions (not 256). Each word is an arrow starting at 0,0 and ending on some X,Y coordinates.

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From Deep Learning Cookbook by Douwe Osinga.

The interesting part about words as vectors is that we can now visualize, in a limited 2D space, how the conceptual distance between the terms man-woman is being translated by the word vectorization algorithm into a physical geometrical distance, which is quite similar to the distance between the terms king-queen. If in only two dimensions the algorithm can generalize from man-woman to king-queen, what can it learn about more complex semantic relationships and hundreds of dimensions?

We can ask such a ML model interesting questions and get answers that are already beyond human level performance:

  • Q: Paris is to France as Berlin is to? A: Germany.
  • Q: Starbucks is to coffee as Apple is to? A: IPhone.
  • Q: What are the capitals of all the European countries? A: UK-London, France-Paris, Romania-Bucharest, etc.
  • Q: What are the three products IBM is most related to? A: DB2, WebSphere Portal, Tamino_XML_Server.

The above are real examples using a a model trained on Google news.

One can train a ML model with relevant vectorized medical text and see if it can answer questions like:

  • Q: Acute pulmonary edema is to CHF as ketoacidosis is to? A: diabetes.
  • Q: What are the three complications a cochlear implant is related to? A: flap necrosis, improper electrode placement, facial nerve problems.
  • Q: Who are the two most experienced surgeons in my home town for a TKR? A: Jekyll, Hyde.

Word vectorization allows other ML models to deal with text (as tensors) — models that do care about the order of the words, algorithms that deal with time sequences, which I will detail in the next articles.

Discrete Categories

Consider a drop-down with the following mutually exclusive drugs:

  1. Viadur
  2. Viagra
  3. Vibramycin
  4. Vicodin

As the above text seems already encoded (Vicodin=4), you may be tempted to eliminate the text and leave the numbers as the encoded values for these drugs. That’s not a good idea. The algorithm will erroneously deduce there is a conceptual similarity between the above drugs just because of their similar range of numbers. After all, two and three are really close from a machine’s perspective, especially if it is a 20,000-drug list. 

The list of drugs being ordered alphabetically by their brand names doesn’t imply there is any conceptual or pharmacological relationship between Viagra and Vibramycin.

Mutually exclusive categories are transformed to numbers with the One Hot Encoder technique detailed above. The result will be a table with the columns: Viadur, Viagra, Vibramycin, Viocodin (similar to the words tokenized above: “the,” “cat,” etc.) Each instance (row) will have one and only one of the above columns encoded with a 1, while all the others will be encoded to 0. In this arrangement, the algorithm is not induced into error and the model will not find conceptual relationships where there are none.

Normalization

When an algorithm is comparing numerical values such as creatinine=3.8, age=1, heparin=5,000, the ML model will give a disproportionate importance and incorrect interpretation to the heparin parameter, just because heparin has a high raw value when compared to all the other numbers. 

One of the most common solutions is to normalize each column:

  • Calculate the mean and standard deviation
  • Replace the raw values with the new normalized ones

When normalized, the algorithm will correctly interpret the creatinine and the age of the patient to be the important, deviant from the average kind of features in this sample, while the heparin will be regarded as normal.

Curse of Dimensionality

If you have a table with 10,000 features (columns),  you may think that’s great as it is feature-rich. But if this table has fewer than 10,000 samples (examples), you should expect ML models that would vehemently refuse to digest your data set or just produce really weird outputs.

This is called the curse of dimensionality. As the number of dimensions increases, the “volume” of the hyperspace created increases much faster, to a point where the data available becomes sparse. That interferes with achieving any statistical significance on any metric and will also prevent a ML model from finding clusters since the data is too sparse.

Preferably the number of samples should be at least three orders of magnitude larger than the number of features. A 10,000-column table had be better garnished by at least 10,000 rows (samples).

Tensors

After all the effort invested in the data preparation above, what kind of tensors can we offer now as food for thought to a machine ?

  • 2D – table: samples, features
  • 3D – time sequences: samples, features, time
  • 4D – images: samples, height, width, RGB (color)
  • 5D – videos: samples, frames, height, width, RGB (color)

Note that samples is the first dimension in all cases.

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Hopefully this article will cause no indigestion to any human or artificial entity.

Next Article

How Does a Machine Actually Learn?

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Morning Headlines 11/7/18

November 6, 2018 Headlines No Comments

Identifying Electronic Health Record Usability And Safety Challenges In Pediatric Settings

A review of EHR-related pediatric medication events in three hospitals that use Cerner or Epic finds that EHR usability contributed to 36 percent of the reports, while 18 percent appear to have caused patient harm.

Premier Inc. Agrees to Acquire Stanson Health to Integrate Data-Enabled Clinical Decision Support Capabilities within EHRs

Premier will acquire clinical decision support vendor Stanson Health for up to $66.5 million in cash.

Phonak teams up with Microsoft to improve access to hearing care over distance

In what might be the first use of teleaudiology, hearing aid manufacturer Phonak will offer access to hearing care professionals to perform online fitting and tuning via its remote support app.

News 11/7/18

November 6, 2018 News 12 Comments

Top News

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A review of 9,000 EHR-related pediatric medication events in three hospitals that use Cerner or Epic finds that EHR usability contributed to 36 percent of the reports, while 18 percent appear to have caused patient harm.

The most common problem areas were lack of system feedback and confusing visual displays.

The authors recommend that ONC add pediatric safety and usability measures to its certification requirements, that vendors and providers use realistic test-case scenarios, and that Joint Commission include EHR safety in its accreditation.


Reader Comments

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From Indigenous Species: “Re: records request. I was a patient of Cleveland Clinic of Florida, which I believe is a big Epic user. They have a fancy patient portal. I used it to request a copy of an operative report and they said I had to contact the medical records department by telephone. I got through the automated attendant to the point I received a message saying I needed to either mail in a request or fax it, after which I could expect something in 10-14 days. Gazillions of dollars spent on Epic and where are we? The same place we were 20 years ago.” Cleveland Clinic Florida’s instructions (above) are embarrassing for any hospital, much less a universally-admired one – in what time warp do patients have a fax machine sitting in their homes (or for that matter, a landline to plug it into)? Why do hospital HIM departments so quickly and firmly reject the idea of printing, signing, scanning, and emailing a completed form (or even better, using DocuSign) in favor of getting their fax fix? Meanwhile, the hospital’s authorization to disclose form is, not surprisingly, a consumer-unfriendly mess for those who just want a copy of their own information. It only covers sending information to someone else, and if that’s not bad enough, the form’s footnote adds, “Cleveland Clinic Florida may, directly or indirectly, receive remuneration from a third party on connection with the use or disclose [sic] of my health information.” That’s an interesting revenue stream – taking a cut of the fees their patients are paying to obtain their own information. I hereby nominate them for my “Least Wired” consumer award, for which they may nose ahead of stiff competition via the form’s outdated reference to “venereal disease.”

From Onion Peeler: “Re: startups. Where can we send our news?” I answered, but this reminds me of a pet peeve. The misused term “startup” should carry an expiration date of maybe 3-4 years, beyond which the defining characteristics — continued outside investment, demonstrably fast growth, lots of industry buzz, and an infrastructure designed to scale — are no longer true. By that point, it’s just a less-sexy sounding small business, not that there’s anything wrong with that. Maybe “startup” should be added to the list of terms that are meaningful only when someone else uses them – innovative, world class, award-winning (preferably detailing who gave the award and for what), and disruptive. Otherwise, it’s just BSaaS. 


Webinars

November 7 (Wednesday) 3:00 ET. “Opioid Crisis: What One Health Plan is Doing About It.” Presenter: Samuel DiCapua, DO, chief medical director, New Hampshire Health Families; and chief medical officer, Casenet. Sponsor: Casenet. This webinar will describe how managed care organization NH Health Families is using innovative programs to manage patients who are struggling with addiction and to help prevent opioid abuse.

Previous webinars are on our YouTube channel. Contact Lorre for information.


Acquisitions, Funding, Business, and Stock

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Premier will acquire clinical decision support vendor Stanson Health for up to $66.5 million in cash. The announcement also notes that Stanson is developing a prior authorization system for medical and pharmacy benefits. Founder Scott Weingarten, MD, MPH, who is also SVP and chief clinical transformation officer of Cedars-Sinai, will remain as leader of the business. Stanson had raised just $3 million in a single Series A funding round in mid-2015.

Alphabet kicks off a two-day, employee-only conference on healthcare on its Sunnyvale, CA campus, featuring outside speakers Eric Topol, MD and former FDA commissioner Rob Califf, MD.

MJH Associates, which runs conferences and magazines such as Pharmacy Times and The American Journal of Accountable Care, acquires Medical Networking, Inc., which operates the Medstro communities and online challenges platforms as well as the Medtech Boston website.


Sales

  • Health First (FL) chooses Kyruus ProviderMatch to allow consumers to find providers and book appointments via its website and call center.
  • Renown Health (NV) implements PeriGen’s PeriWatch labor analysis software in its childbirth unit, including its Cues fetal surveillance solution.
  • FQHC Community Healthcare Network (NY) will use Valera Health’s smartphone-based patient engagement solution for patients with behavioral and chronic health conditions.
  • Massachusetts General Hospital chooses CarePassport for patient monitoring and engagement in its research studies. The company’s founder is Mohamed Shoura, PhD, who is also CEO of imaging vendor Paxera Health (formerly Paxeramed).
  • LStar Imaging (TX) chooses ERad for imaging.

People

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Collective Medical hires Kat McDavitt (Insena Communications) as chief marketing officer.

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Cantata Health names Tad Druart (ESO Solutions) as chief marketing officer.

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Health IT security and patient engagement technology vendor Intraprise Health hires industry long-timer Sean Friel (Voalte) as president.


Announcements and Implementations

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Microsoft will shut down HealthVault’s Direct messaging service as of December 27, 2018, according to an email forwarded by a reader. The company did not provide a reason. The company says “other messaging services” are available, but the notice doesn’t list them and I saw no alternatives on its website except for CCD exchange. I’ve emailed Microsoft’s press contact but haven’t received a response.

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In what might be the first use of teleaudiology, hearing aid manufacturer Phonak will offer access to hearing care professionals to perform online fitting and tuning via its remote support app. The company’s rechargeable hearing aids can already connect to mobile devices via Bluetooth to provide optimized sound quality for TV, music, and phone calls and its MyCall-to-Text app converts telephone conversations to text in real time. Hearing aids are inherently unexciting unless you need them (or need to pay for them, which is exciting in all the wrong ways), but this seems like pretty cool technology. Switzerland-based parent company Sonova Group is the world’s biggest hearing care solutions vendor (or close to it) with 14,000 employees and $2.7 billion in annual sales.

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A KLAS report on how well EHR vendors serve non-US regional needs finds:

  • Epic performed best with no dissatisfied customers.
  • Cerner finished second despite not engaging proactively and often at extra cost.
  • Meditech does well in Canada, UK, and Ireland although with concerns about slow growth and development.
  • No Allscripts customers report high satisfaction and they often feel they’re on their own to implement.
  • InterSystems has trending sharply down in the past two years due to staffing problems.
  • Latin America is led by MV (which is increasing its lead) and Philips.
  • InterSystems has slipped behind Cerner in the Middle East, while Epic has the highest score but just three live sites as prospects would like to see increased regional presence and expertise.
  • Cerner and InterSystems lead in Asia/Oceania, as Allscripts customers express low confidence in the company’s R&D efforts and its acquisition strategy.

China’s Tencent announces an AI-powered smart microscope whose voice interface allows pathologists to issue commands and reports.

In England, East Kent Hospitals University goes live with the Allscripts patient administration system.


Other

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Atul Gawande’s piece in The New Yorker titled “Why Doctors Hate Their Computers” makes these points:

  • Computers have simplified tasks in many other industries, but have made enemies of their healthcare users.
  • Partners HealthCare’s $1.6 billion Epic implementation involved less than $100 million worth of Epic software, with the remainder of the cost being lost patient revenue and the cost of implementation staff.
  • Epic SVP Sumit Rana describes “The Revenge of the Ancillaries,” where ancillary departments are given a seat at the implementation table and influence decisions to make their jobs easier while forcing required fields and additional data entry on doctors.
  • A busy internist colleague says Epic has reduced her efficiency, requiring her to finish documentation after going home and to struggle with a jammed Epic in basket to the point that she just deletes messages without reading them.
  • The ability for everyone to modify the problem list has made it useless, requiring a review of past notes that are often excessively lengthy due to copying and pasting.
  • Gawande quotes an author who in the 1970s described how users initially embrace new capabilities with joy, then come to depend on them, then find themselves faced with the choice of submitting or rebelling to the system’s control over their lives.
  • An office assistant notes that much of the work she performed has been shifted to Epic-using doctors.
  • Partners HealthCare’s chief clinical officer, who has been through four EHR implementations, says Epic is for the patients who look up their lab results, review their medication instructions, and read the notes their doctors have written about them. He also notes that the EHR supports population health management and research.
  • Partners uses scribes, but due to concerns about turnover and errors, they chose an offshore service in which India-based doctors create visit documentation from digitally recorded encounters. A 30-minute visit requires an hour to document, with the result then reviewed by a second company doctor as well as a coding expert who looks for billing opportunities. However, as Gawande observes, “What is happening across the globe? Who is taking care of the patients all those scribing doctors aren’t seeing?”

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Epic further explains how the recently mentioned New York Life integration works. People applying for life insurance ordinarily have to supply their medical history on paper after obtaining it from their hospital, a slow and expensive process. The integration uses Epic’s Chart Gateway service, which when authorized by the patient and the health system, sends information electronically to life insurance companies. It’s not blanket access to MyChart or to the data of any other patients. This is the first time I’ve heard of Chart Gateway.

The Wall Street Journal explains why smart speakers like Amazon Echo can’t make voice-requested 911 calls, at least for now: (a) lack of GPS precision; (b) inability to be called back by operators; and (c) users would need to pay 911 surcharges as they do for cell service.


Sponsor Updates

  • EClinicalWorks publishes a podcast titled “How PRM Services Boosted Youth Engagement in NYC.”
  • The Chicago Tribute names Intelligent Medical Objects as a “Top Workplace.”
  • Former Pepsi and Apple CEO John Sculley will deliver the keynote address at MDLive’s user group meeting Wednesday at 9:30 a.m. EST, with his presentation live-streamed.

Blog Posts


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Contacts

Mr. H, Lorre, Jenn, Dr. Jayne.
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Morning Headlines 11/6/18

November 5, 2018 Headlines No Comments

ResMed to Acquire MatrixCare, Expands Out-of-Hospital SaaS Portfolio into Long-Term Care Settings

Connected health vendor ResMed will acquire LTPAC EHR and quality software vendor MatrixCare for $750 million.

Social Determinants Of Health: Holy Grail Or Dead-End Road?

A Forbes article says that addressing social determinants of health can’t improve health outcomes on its own, calling for improving food literacy, enhancing the respectful relationship between patients and providers, and addressing poverty and the lack of economic opportunity that often override health needs.

Exact Sciences signs deal with Epic Systems, hikes sales, widens losses

Madison, WI-based cancer screening test vendor Exact Sciences will implement Epic for “order entry all the way through revenue cycle and customer care.”

Cancer Society Executive Resigns Amid Upset Over Corporate Partnerships

American Cancer Society EVP/Chief Medical Officer Otis Brawley, MD resigns after negative reaction to the organization’s commercial partnerships with companies with questionable health credentials, such as Herbalife International, Long John Silver’s, and the Tilted Kilt bar chain.

Curbside Consult with Dr. Jayne 11/5/18

November 5, 2018 Dr. Jayne 3 Comments

A reader recently asked for Mr. H’s prediction on what to expect from Medicare’s “Patients Over Paperwork” initiative. Mr. H asked me to chime in, along with readers, with my thoughts on the proposed changes to E&M codes, office visit documentation, and other paperwork.

He noted that, “It’s hard to separate meaningful HHS/CMS announcements from the political rhetoric spouted by its campaigner-appointees, so I’ve quit trying.” I agree that it’s a quite a challenge to figure out what is going on with CMS lately, since there seem to be many announcements talking about how great things are going to be, but with little change for the people actually doing the boots-on-the-ground work.

I’ve been shocked by the level of rhetoric in CMS announcements under the new administration. Everything seems to have been cranked up a notch and things that need not be political are being politicized. Healthcare finance and payment for providers is complicated and divisive enough and doesn’t need red vs. blue overtones applied on top of it all.

As to the initial question, I think that some of the details in finalizing the 2019 Physician Fee Schedule (PFS) and Quality Payment Program (QPP) rules show that the current CMS/HHS leadership might have bitten off more than they can chew. Physicians were initially excited about a potential move to overhaul Evaluation and Management (E&M) coding, creating fewer “blended” codes that were purported to more accurately reflect the work being done by physicians during office visit encounters. Although there was some positive excitement, the majority of the 15,000 comments that CMS received were negative, according to multiple reports (for those of us who didn’t read all of them). On November 1, CMS responded to that dichotomous excitement by delaying changes to those visit codes until 2021.

It’s important to remember that even though CMS ostensibly only makes the coding rules applicable to Medicare patient visits, because of how things work, they’re pretty much applicable to everyone, including commercial insurance payers and Medicaid. Self-pay patients are impacted somewhat, depending on how practices handle those patients.

The overall sentiment cited in the announcement of the delay was concern by physicians that the planned blending would reduce payments to physicians caring for Medicare patients with complex health conditions and/or multiple chronic conditions. CMS will now plan to consolidate the codes from eight to three instead of the originally-proposed two, preserving the “level 5” code used for the most complex (and most time-consuming) office visits. Another two years are needed to work out the details, apparently. CMS Administrator Seema Verma is quoted as saying, “We know this is going to have a tremendous impact on many physicians in America. We want to get it right.”

I take issue with that comment. If you knew it was going to have such a huge impact, why did you think it was OK to go ahead and put it in the most recent proposed rule? Wouldn’t it have been better to put together some working groups or task forces, etc. including actual working physicians rather than cobbling together something internally and then having to take it back? To an in the trenches physician, this back and forth makes one feel like CMS doesn’t understand us and that it has become reactionary rather than proactively addressing the issues that all of us face. If the wheel was less squeaky, would this have moved along?

The American Medical Association and the Medical Group Management Association are in support of the delay, noting in various press releases and on-the-record comments that the plan was flawed. MGMA SVP of Governmental Affairs Anders Gilberg stated, “Blending payments rates in 2021 won’t necessarily reduce burden, especially with CMS’ newly required add-on codes.” More than 150 various medical societies signed on to a letter opposing the new structure prior to the announcement of the delay.

CMS claims that proposed changes will simplify the way physicians bill for visits, and along with other modifications, are expected to save clinicians $87 million in administrative costs in 2019, ultimately yielding a net savings if $843 million over the coming decade and 21 million hours by 2021.

You know what would also save money and reduce physician angst, possibly slowing the retirement and exodus of much-needed clinicians? Stop harassing physicians with coding audits. Practices constantly receive requests from their Medicare intermediaries asking for documentation to justify the various codes. The practices I work with have gotten responding to these down to a fine science, trying to waste as little of their time as possible. Most of them have a 95 percent or greater success rate in justifying their codes.

I agree that means that five percent of the time they are overcoding or undercoding, but does catching that justify the millions of hours spent dealing with the audits? How about targeting the most egregious offenders and letting the rest of the physician base spend their staff resources managing patients rather than printing and mailing/faxing records to auditors? Burden isn’t just a financial problem – it’s a psychological one and is closely associated with clinician burnout.

Notwithstanding the delay in the E&M codes, CMS is moving forward with other elements of the Rule (and other proposed rules) that are supposed to reduce burden or save money. Physicians can focus on documentation of the interval history since the previous visit, rather than re-documenting previously documented information just for the sake of documentation. Physicians will not have to re-document the chief complaint and history of present illness already documented by their staff or by the patient himself/herself, just because the rules require it. Wholesale acquisition costs for Medicare Part B drugs are supposed to be lowered with the savings passed on to consumers. The so-called “Meaningful Measures” plan should simplify quality reporting for various federal programs that often do not align. Telehealth services and remote monitoring under home health should save money.

As I try to put my thoughts together on this complex topic, my blood pressure is definitely rising. I struggle with the conundrums that we’re facing in healthcare today, at least in the way that I have boiled them down so that I can attempt to understand them:

  • We don’t want universal healthcare, but we want universal control over how physicians and facilities bill and how they are paid.
  • We want to set up complex rules to control payments, but then we get upset when organizations figure out how to game the system (RIP, provider-based billing).
  • We don’t want higher-quality physicians to be able to charge more for their services on the front end, but want to spend loads of administrative money trying to incent them (or penalize others) on the back end.
  • We don’t want to require payers and employers to cover a universally agreed-upon subset of preventive services and money-saving interventions such as birth control, but we want to reduce disease burden and lower the rate of poverty.
  • We want the most high tech services in the world regardless of whether they’re indicated, but we don’t want limits on those services based on ability to pay or overall financial burden to society.

There are many other elements I could cite, but I’d like to preserve some good spirits for the rest of the day and a charity project I’m about to go work on. I wonder, though, as policy-makers debate the solutions they propose for all of this, if they really think about both sides of the various equations or whether we’ve gotten to such a position of polarization that they can only see their own perspective.

What do you think about the Patients Over Paperwork initiative? Leave a comment or email me.

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Morning Headlines 11/5/18

November 5, 2018 Headlines 5 Comments

Allscripts Healthcare Solutions (MDRX) Q3 2018 Results – Earnings Call Transcript

Allscripts executives comment on the potential sale of Netsmart and its plan to increase margins for the former McKesson EIS business, but fail to directly answer a question about plans of its biggest client Northwell Health and make no mention of its Avenel EHR that was announced at HIMSS18.

OpenText to Acquire Liaison Technologies, Inc.

Information management technology vendor OpenText will acquire competitor Liaison Technologies for $310 million in cash.

Like clockwork: How daylight saving time stumps hospital record keeping

Users describe how they work around Epic’s inability to handle documentation entries between 1:00 a.m. and 2:00 a.m. when clocks are moved back at the end of daylight saving time.

Why Doctors Hate Their Computers

Atul Gawande, writing about his experience with Epic’s go-live at Partners HealthCare, says EHRs were supposed to increase the mastery of doctors over work, but have actually increased work’s mastery over doctors. He quotes an Epic executive’s description of “the Revenge of the Ancillaries,” where the go-live allowed non-doctors to influence their workflow in unproductive ways. He also notes that EHRs have made the problem list nearly worthless and that Epic’s In Basket is “clogged to the point of dysfunction.” He also quotes Partners Chief Client Officer Gregg Meyer, who reminds that Epic is for the patients, not the doctors, and is at least mildly enthusiastic about using scribes. 

Monday Morning Update 11/5/18

November 4, 2018 News 10 Comments

Top News

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From the Allscripts earnings call following release of poor quarterly numbers that sent shares down 19 percent Friday:

  • The company will launch a formal sales process for its share of Netsmart, which it says is a complex transaction because of the terms of the joint venture agreement between the companies. 
  • Netsmart’s Q3 business performance was “lighter than we expected” and executives on the call repeatedly stated how much better the Allscripts numbers would have been without Netsmart (which isn’t exactly talking up a planned divestiture), although CEO Paul Black said, “we are very bullish about Netsmart’s prospects whether or not a transaction is ultimately consummated in the near term.”
  • Northwell Health extended its TouchWorks agreement for another five years. Questioned by an analyst about whether Northwell (which is the largest customer of Allscripts) will also extend its Sunrise agreement, President Rick Poulton waffled, saying only that Northwell has one year left on its managed services agreement and that it’s not a high-margin business.
  • The company says it and its competitors know that the EHR and revenue cycle solutions market is mature and the churn isn’t going to generate a lot of net profit for anyone. Allscripts will ramp up services offerings to offset the decline.
  • The company again did not mention its previously highly touted Avenel EHR that was unveiled at HIMSS18.
  • Allscripts hopes to increase the margin of the former McKesson EIS business from single-digits to 18-20 percent.
  • The company says retention of customers of the formerly free Practice Fusion is strong after Allscripts started charging for it, adding that Allscripts is blending that business in with its payer and life science offerings (Practice Fusion runs drug company ads and sells de-identified patient data to pharma).

Reader Comments

From Lil’ Mob: “Re: Healthcare Informatics sold. HIStalk is the rare, independent voice in this space.” Vendome sells Healthcare Informatics magazine to another publisher whose goal is helping vendors “bring their services and products to market” (which I take to mean that seldom is heard a discouraging word that might make the ad salespeople’s job harder). For example, the four most important news stories of last week were not flattering to vendors – ProPublica’s critical assessment of the VA’s Cerner implementation, poor quarterly results from Allscripts and NextGen Healthcare, and Orion Health’s desperation-fueled sale of Rhapsody. None of those stories appear on the websites of the magazines that finished most closely (but still way behind) HIStalk in Reaction Data’s C-level provider survey. They instead ran with these questionably useful stories:

  • Is emotional support part of AI’s future in healthcare?
  • In Northern Virginia, Rethinking ACO Strategies—For PCPs and Specialists
  • Royole’s bendy-screen FlexPai phone unveiled in China

HIStalk Announcements and Requests

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Most poll respondents are proud of what their employer sells. New poll to your right or here: what are your HIMSS19 plans?


Webinars

November 7 (Wednesday) 3:00 ET. “Opioid Crisis: What One Health Plan is Doing About It.” Presenter: Samuel DiCapua, DO, chief medical director, New Hampshire Health Families; and chief medical officer, Casenet. Sponsor: Casenet. This webinar will describe how managed care organization NH Health Families is using innovative programs to manage patients who are struggling with addiction and to help prevent opioid abuse.

Previous webinars are on our YouTube channel. Contact Lorre for information.


Acquisitions, Funding, Business, and Stock

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Information management technology vendor OpenText will acquire competitor Liaison Technologies for $310 million in cash.

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England’s NHS Digital will eliminate 500 jobs in a restructuring, about 20 percent of its staff.

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Apple turns in record Q4 numbers driven by jacked-up prices rather than increased sales or innovation. Shares sank Friday after the company announced that it will no longer provide individual unit sales or average prices, which would lead to the conclusion that (a) the company plans to hold price-insensitive fanboys hostage to make its numbers; and (b) Apple would rather not publicize the fact that it’s milking the cash cow harder (in a mature market in which its products are the highest priced) by increasing services and add-on revenue per customer, which isn’t very transparent for a traditionally transparent company. Much of the market won’t pay baseline prices of $1,300 for an IPhone, $1,800 for a Macbook Air, $399 for an Apple Watch, or $799 for an IPad Pro. Meanwhile, the company kicks the latest dent in the universe in an enhancement to the IPad, which will no longer offer a headphone jack. 


People

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Dean Smith, MD, MBI (US Department of State) joins GlobalMed Telemedicine as CMIO/SVP of government relations.


Announcements and Implementations

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Epic signs an agreement to give insurer New York Life direct access to its EHR to extract information for people who are applying for life insurance.

PatientPing adds the capability to tag patients who are covered under bundled payment models.


Government and Politics

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The Federal Trade Commission shuts down a Florida company that sold $100 million worth of worthless health insurance plans, saying that Simple Health Plans LLC misled purchasers into thinking that its medical discount program – which cost up to $500 per month — was actual insurance. The “insurance” does not cover pre-existing conditions or prescriptions, pays a maximum of $100 per day for hospitalization, and has a yearly cap of $3,200 and even then only if the patient is hospitalized for 30 days or more. The government’s restraining order also calls for seizing the owner’s $1 million bank account and his Lamborghini, Range Rover, and Rolls-Royce.


Privacy and Security

Defunct Georgia-based Best Medical Transcription pays $200,000 to settle charges that it exposed the information of patients of Virtua Medical Group (NJ) to Internet searches, a problem reported by a patient who Googled herself and found her own medical records. The New Jersey attorney general also banned Best Medical owner Tushar Mathur from doing business in the state.


Other

Kaiser Health News notes that Epic can’t handle vital signs entered between 1:00 a.m. and 2:00 a.m. on the Sunday when daylight saving time ends because those entries will be deleted when the clock is set back, forcing hospitals to document manually until after the time change. The articles says that nurses at Johns Hopkins and Cleveland Clinic date their entries after the time change to 1:01 a.m., but add a note that the vital signs were actually taken an hour after the previous entries rather than just one minute.

Steve Ballmer becomes the latest rich person to donate millions to a hospital, leading me to implore the financially fortunate to support public health, not expensive healthcare service vendors (even if their customer base consists of heartstring-tugging children). Seattle Children’s doesn’t really need Steve’s $20 million – last year it had a $224 million profit on $1.4 billion in revenue – and it’s a shame that such tech titan largesse is always focused on their home cities like Seattle, San Francisco, and Palo Alto.

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A Boston Globe magazine piece called “Losing Laura” describes the death of a 34-year-old woman who walked to the ED of Somerville Hospital while experiencing an asthma attack but couldn’t get in because of a confusingly marked entrance and the inability of 911 operators to pinpoint her precise location on the campus. She collapsed outside a locked glass door through which she could see the ED waiting area, and a hospital nurse who went outside to look for her from the 911 call didn’t notice her on the ground. I’m at least a little bit sympathetic to the hospital, which is otherwise being sued and cited by the state – EDs in suburban hospitals were not usually designed for walk-up access in life-threatening emergencies. The article notes that while Uber and Lyft drivers are guided directly to their fares with near-perfect accuracy, the FCC requires cell providers to locate a 911 caller only to within 300 meters.

In India, a judge who is annoyed at deciphering illegible doctor handwriting on injury and death reports requires them to print and sign transcribed copies from their computers. The same court previously ordered doctors to write legibly and fined those who didn’t, but the problem persisted.

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The author of the bestselling “PH Miracle” book series, who claimed that an acidic diet causes disease and offered treatments around that principle, is ordered to pay $105 million to a cancer patient who sued him for negligence and fraud. The author, who had already served jail time for practicing medicine without a license, advised the patient – who was also a former employee of his — to forego traditional cancer treatment and instead let him take over with sodium bicarbonate IVs administered at his $3 million ranch.


Sponsor Updates

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  • Lightbeam Health Solutions employees team up with Habitat for Humanity in Dallas.
  • LogicStream Health will exhibit at the National Association for Healthcare Quality Conference November 5-7 in Minneapolis.
  • CitiusTech names seven industry leaders to its advisory board.
  • CHIME elects Meditech EVP Helen Waters to the CHIME Foundation Board.
  • Mobile Heartbeat will host a user group meeting November 7-9 in Sunny Isles Beach, FL.
  • Netsmart will exhibit at the National Hospice and Palliative Care Organization Fall Conference November 5 in New Orleans.
  • Nordic will host a reception during the Population Health and Connect Summit November 7 from 6:30-8:30pm in Madison, WI.
  • Clinical Computer Systems, developer of the Obix Perinatal Data System, will exhibit at the Michigan Critical Access Hospital Conference November 8-9 in Traverse City.
  • OnPlanHealth announces a partnership with the Dallas-Fort Worth Hospital Council.
  • Meditech recaps its Physician and CIO Forum.
  • KLAS recognizes PatientSafe Solutions and Voalte as top vendors in its “Decision Insights: Secure Communication 2018” report.
  • Pivot Point Consulting will exhibit at the 2018 HIMSS Virginia Fall Conference November 5-7 in Williamsburg, VA.
  • The SSI Group will exhibit at the Georgia HFMA Fall Institute November 7-9 in Savannah.
  • Sunquest Information Systems will exhibit at the ATLAS Medical User Group November 6-7 in Chicago.
  • Waystar will exhibit at CHUG Southeast November 8-10 in Nashville.
  • Surescripts will exhibit at the NextGen User Group Meeting November 11-14 in Nashville.
  • SymphonyRM will host a networking event at HCIC18 November 6 from 7-10pm in Scottsdale, AZ.
  • AMIA includes TriNetX VP of Informatics Matvey Palchuk in its inaugural class of fellows.

Blog Posts


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Contacts

Mr. H, Lorre, Jenn, Dr. Jayne.
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Weekender 11/2/18

November 2, 2018 Weekender No Comments

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Weekly News Recap

  • A ProPublica investigative article questions the VA’s selection of Cerner, its management of the implementation, its choice of questionably experienced project leadership, and the gap between the original lofty goals and the reality of what Cerner is delivering
  • Allscripts and NextGen Healthcare turn in disappointing quarterly results that sent shares sharply down
  • McKesson Chairman and CEO John Hammergren announces his March 2019 retirement
  • Orion Health finalizes the sale of its Rhapsody integration engine to Hg, which will sell and support it as an independent company
  • Seattle-based 98point6 raises $50 million to expand its chat-powered “virtual primary care” unlimited service
  • A report blames Cerner for May 2017 outages at seven Queensland Health hospitals, refuting the Australian health system’s initial claim that the downtime was caused by ransomware
  • Cerner says in its earnings call that its DoD and VA work will drive growth until its population health management business takes off
  • Analysts speculate that IBM’s $34 billion acquisition of Red Hat may signal a Watson wind-down and a return to enterprise software and services
  • Roper Technologies says in its earnings call that revenue of its Sunquest business is trending down due to competitive pressure and that it will be “rebasing” the business

Watercooler Talk Tidbits

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Readers funded the DonorsChoose teacher grant request of Ms. S in Colorado, who asked for a “huge box of math tools and games” (actually 17 items in total) for her elementary school class. She reports, “Thank you so much for sending us such amazing math games. I can honestly say that kids are loving math more than ever. They loved the dice game you sent us called Math Chase. One kid rolls one large dice and then proceeds to roll five other colored dice. They have to use the five other dice to make the number on the large dice. They can use addition, subtraction, multiplication, or division and it requires so much critical thinking. It has been so great to see kids apply the skills we have been learning. Now they can’t wait for math class because they know it will be fun!”

Wired magazine notes that Stanford has enrolled a huge umber of study patients whose heartbeat will be monitored from their Apple Watch, but questions whether screening huge numbers of people who don’t have symptoms will result in better care instead of misdiagnosis, unnecessary testing, and overtreatment. It also notes that Apple will release EKG and irregular rhythm features to the general public before the study is finished.

Memorial Healthcare Systems (FL) markets its telehealth service to South Florida hotels, hoping to recruit visitors and tourists for the $59 service.

Brigham Health uses text-based patient engagement for colonoscopy patients, reminding those who are scheduled for the procedure to complete their prep correctly. The no-show rate has dropped from six percent to four percent, while the number of poorly prepped patients has decreased from 11.5 percent to 3.8 percent.

Female medical students taking Canada’s licensing exam complain about #tampongate, their term for the test’s requirement that feminine hygiene products be declared and inspected upon entry.

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CNN notes the irony that while the man charged with killing 11 people at a Pittsburgh synagogue was screaming “I want to kill all the Jews” in the ambulance and ED, the nurse treating him and the hospital president who stopped by to check on him were both Jewish. Allegheny General Hospital President Jeffrey Cohen, MD — who is a member of the Tree of Life synagogue where the shooting occurred — said, “We don’t ask questions about who they are. We don’t ask questions about their insurance status or whether they can pay. To us, they’re patients.” He added a comment about the alleged shooter: “The gentleman didn’t appear to be a member of the Mensa society. He listens to the noise, he hears the noise, the noise was telling him his people were being slaughtered. He thought it was time to rise up and do something. He’s completely confused.”


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Morning Headlines 11/2/18

November 1, 2018 Headlines No Comments

The VA Shadow Rulers’ Signature Program Is “Trending Towards Red”

ProPublica highlights the political power struggles and leadership mismanagement surrounding the VA’s no-bid, $10 billion Cerner project, prompting the software vendor to preemptively warn veterans groups of negative media coverage.

McKesson says Chairman/CEO Hammergren to retire, succeeded by Tyler

McKesson CEO John Hammergren will retire on March 31, 2019, to be replaced by President/COO Brian Tyler.

NextGen Healthcare Inc (NXGN) CEO Rusty Frantz on Q2 2019 Results – Earnings Call Transcript

NextGen Healthcare CEO Rusty Frantz reports Q2 results that beat earnings expectations but fall short on revenue, adding that the company is making a push to upgrade the 50 percent of its clients that are on older product versions.

Allscripts stock drops as quarterly results miss Street view

Allscripts reports Q3 results: revenue up 16 percent, EPS $-0.20 vs. –$0.16, missing Wall Street expectations for both.

News 11/2/18

November 1, 2018 News 4 Comments

Top News

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ProPublica investigates the VA’s no-bid, $10 billion Cerner project, with these findings:

  • Trump advisor and son-in-law Jared Kushner pushed the no-bid selection of Cerner, naively assuming that interoperability would be automatic if VA and DoD used the same company’s product. “The premise of all of this is incorrect,” a former project official now concludes, adding, “We thought it made perfect sense until we looked under the hood.”
  • The VA team, which justified choosing Cerner without a bidding process by claiming it would create “seamless care,” has stopped using that term and now just says VA doctors will be able to see DoD records, which they can already do with their old systems.
  • The White House rejected qualified candidates for CIO and other oversight roles and instead proposed former Trump campaign officials who have no health IT experience.
  • One of those rejected candidates was former Sutter Health CIO Jon Manis, who questioned the role of Bruce Moskowitz, MD — the physician member of the Mar-a-Lago group of Trump supporters that was reported to be meddling in VA affairs – and feared that the project’s politics and instability would make the job impossible.
  • Since-fired VA Secretary David Shulkin, MD sent Cerner reps packing when they showed PowerPoints instead of something real, explaining that he planned to hold Cerner to a higher standard than just installing its standard software. He expected to create a single lifetime health record with computerized decision support.
  • A group of hospital executives warned the VA that Cerner’s off-the-shelf product and VA-DoD data synchronization would not by itself achieve the VA’s goal of seamless care.
  • The VA’s project to mine EHR data for key clinical insights was abandoned with the selection of Cerner, which turned out to not have those capabilities.
  • Cerner was found to be missing key VA capabilities such as Agent Orange exposure, spinal cord injury, and PTSD.
  • Intermountain Healthcare CMIO Stan Huff told the VA, “If you install Cerner as an off-the-shelf product, your clinicians are going to be extremely unhappy and everybody is going to ask why did you spend billions of dollars for a crappy system.”
  • The DoD has proposed sending only 1-3 years of service member and dependent records to the VA’s new system.
  • Since-resigned VA CHIO Genevieve Morris could not get VA clinicians to participate and found herself in a political power struggle with new CIO Camilo Sandoval (no health IT experience), John Windom (whose expertise is procurement), and Rich Stone, MD (the VA’s top health official).
  • The VA spent at least $874,000 on a kickoff event held at Cerner’s headquarters, where Morris and Windom argued over stage time and walk-on songs and tried to gloss over the project’s convoluted org chart.
  • Cerner’s internal progress report rates the project’s alert level as “yellow trending towards red.”
  • The DoD is so concerned about VA’s project oversight that they have proposed taking the project over, although the Pentagon’s lawyers said that probably isn’t legal.

Cerner has reportedly emailed veterans groups to warn them of “negative media coverage, including a piece from ProPublica.”


Reader Comments

From Fortune Teller: “Re: Medicare’s Patients Over Paperwork initiative. Do you have a prediction on what to expect?” I’ll let readers and Dr. Jayne chime in on the proposed changes to E&M codes, office visit documentation, and other paperwork that were first floated by CMS a year ago. It’s hard to separate meaningful HHS/CMS announcements from the political rhetoric spouted by its campaigner-appointees, so I’ve quit trying.


HIStalk Announcements and Requests

I added a “Add/Read Comments” button at the bottom of this post. It will make it easier to add a comment after reading. Let me know what you think.

Mrs. HIStalk shamed me into accompanying to seeing yet another movie (a rarity for me), in which case I give “First Man” a B- for being dull, presumably accurate, and nausea-inducing for using the “shaky cam” such that living room scenes are far harder to watch than when Gemini and Apollo spacecraft are careening wildly through space (“The Right Stuff” is about a hundred times better in every way). Before that, I laughed out loud at the preview of awful-looking sing-along, Queen-approved puff piece “Bohemian Rhapsody” as the audience all reflexively ducked to avoid being gored by the massive fake teeth of Freddy Mercury (Rami Malek).


Webinars

November 7 (Wednesday) 3:00 ET. “Opioid Crisis: What One Health Plan is Doing About It.” Presenter: Samuel DiCapua, DO, chief medical director, New Hampshire Health Families; and chief medical officer, Casenet. Sponsor: Casenet. This webinar will describe how managed care organization NH Health Families is using innovative programs to manage patients who are struggling with addiction and to help prevent opioid abuse.

Previous webinars are on our YouTube channel. Contact Lorre for information.


Acquisitions, Funding, Business, and Stock

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Orion Health finalizes its sale of Rhapsody to technology investment firm Hg, enabling Rhapsody to launch as an independent company in Boston under the leadership of former McKesson executive Erkan Akyuz. The company, which offers health data integration software, plans to increase staff by 40 percent over the next 18 months.

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Bloomberg reports that Elliott Management and Veritas Capital have teamed up to bid on Athenahealth. Veritas acquired GE’s ambulatory care, revenue-cycle, and workforce management software business for $1 billion in April.

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Allscripts reports Q3 results: revenue up 16 percent, EPS $-0.20 vs. –$0.16, missing Wall Street expectations for both. Shares were down 9 percent in early after-hours trading Thursday following the announcement.

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NextGen Healthcare, in its first quarterly report since changing its name from Quality Systems, Inc. on September 10, reports Q2 results: revenue down 2 percent, adjusted EPS $0.24 vs. $0.22, beating earnings expectations but falling short on revenue. Shares dropped 24 percent on the news, valuing the company at $968 million. From the earnings call:

  • Customer attrition rate in the trailing 12 months was higher than expected at 13.9 percent, as “Epic clients continue to sweep through their physician practices and as Cerner continues to convert the Siemens ambulatory base post-acquisition.”
  • The company will “sort of be proactive. We’re actually getting in and optimizing those clients long before they ever even think about whether or not there is a different opportunity available for them within their local ecosystem.”
  • The company has eliminated the COO role that was vacated with Scott Bostick’s resignation in September 2018, with sales and services now reporting directly to the executive team.
  • The company will add new financial services and contract management offerings.
  • Long implementation cycles with all-in customers reduced the conversion of bookings to revenue.
  • President and CEO Rusty Frantz said in response to an analyst’s question about one-time accruals that it was “my least favorite one-time accrual … lowering the management incentive plan because our expectations on revenue are not what they were at the beginning of the year.”
  • NextGen isn’t seeing any sales benefit of Athenahealth’s tribulations, saying that ambulatory physicians look purely at products rather than investor-side activity.
  • The company is making a push to upgrade the 50 percent of its clients that are on older product versions and will eventually implement end-of-life support.

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Meditech reports Q3 results: revenue down 2 percent, EPS $0.52 vs. $0.47. Product venue slipped 7 percent due to implementation delays.


People

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McKesson CEO John Hammergren will retire on March 31, 2019. to be replaced by President/COO Brian Tyler.

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PeraHealth hires industry long-timer Greg White (PerfectServe) as CEO.


Sales

  • Hawaii Health Information Exchange will implement NextGate’s cloud-based provider registry and enterprise master patient index.
  • Asquam Community Health Collaborative (NH) signs a managed services agreement with Huntzinger Management Group for LRGHealthcare and Speare Memorial Hospital. Asquam’s IT staff will become Huntzinger employees.
  • Citizens Medical Center (TX) selects automated pre-bill coding analysis software from Streamline Health Solutions.
  • Lake Regional Health System (MO) will implement Cerner Millennium in collaboration with University of Missouri Health Care.
  • Inova Health System (VA) will expand the rollout of Spok Care Connect clinical alerting beyond its initial implementation at Inova Fairfax Hospital.

Announcements and Implementations

Adventist Health System (FL) implements Glytec’s EGlycemic Management System at 33 facilities in seven states.


Government and Politics

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Cerner Government Services President Travis Dalton provides an update on the company’s DoD and VA software implementation efforts, highlighting workflow and care improvements made at the initial DoD implementation sites and the company’s receptiveness to progress reports from those facilities, which, as he acknowledges, have been seen by some as setbacks. He adds that the company is ready to kick off implementations at military medical facilities in California and Idaho.

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HHS re-launches the Healthcare Cybersecurity and Communications Integration Center as the Health Sector Cybersecurity Coordination Center. HC3 will operate under the authority of the Department of Homeland Security. The initial HCCIC suffered from organizational delays and leadership setbacks tied to allegations of ethics violations that led to an OIG investigation.


Privacy and Security

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A reader sent this Reddit-posted breach item claiming that employee and dependent information from Cerner’s health plan was posted to a company wiki and had been visible internally for nearly a year. I reached out to Cerner and received this response:

Some data about associate benefits was posted on a password-restricted intranet site. The personally identifiable information was not exposed or accessed by anyone from outside the company. The data was viewed by a small group of associates, all of whom have had extensive HIPAA training. Due to the limited nature of the exposure, we determined that this did not constitute a data breach and we are not formally reporting this matter.


Other

IBM’s Red Hat acquisition will enable it to move Watson Health services to a hybrid cloud model, which the company says will give customers easier access to data for analytics and AI projects. Initial converted data sets will include claims and patient data from IBM’s Truven Health Analytics, Explorys, and Phytel acquisitions.

A Kaiser Health News report says that precision medicine for cancer treatment sounds good, but insurers cover the cost poorly if at all because the treatments are off label and evidence is lacking that they extend lifespan. The article profiled a breast cancer patient who can’t afford the $17,000 per month cost of AstraZeneca’s drug, and after the story ran, the drug company immediately offered to comp it (thus proving that in our unbelievably screwed-up healthcare non-system, the biggest shortage we have isn’t of doctors or other clinicians, but rather reporters).

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A nurse in Germany who is serving a life sentence for killing two hospitalized patients confesses to killing at least 100 more in two hospitals, explaining that he enjoyed trying to resuscitate the patients he chose randomly to inject with arrhythmia-inducing drugs. Authorities and the families of his alleged victims question why he wasn’t caught sooner, even in one case in which he was caught in the act of injecting a patient but was allowed to work for another two days, during which time he killed another one. Hospital records showed that death and resuscitation rates doubled when he was working, a nice piece of analytical work in every way except timeliness.


Sponsor Updates

  • Mobile Heartbeat attains 100,000 monthly active users of its MH-CURE unified clinical communications platform.
  • EClinicalWorks will exhibit at AAP 2018 November 3-5 in Orlando.
  • Allina Health CIO Jonathan Shoemaker and Health Catalyst win CHIME’s 2018 Collaboration Award.
  • Nuance shares results following Piedmont Healthcare’s implementation of the company’s clinical documentation products.
  • Formativ Health publishes a new white paper detailing ways providers can grow and maintain their patient panels.
  • Kids Rock Cancer Center shares how FormFast has benefitted its care team.
  • Glytec publishes a new e-book, “Hypoglycemia in the hospital. Why is it costing you millions and what can you do?”
  • CHIME names Nuance Communications VP Kali Durgampudi its 2018 Foundation Industry Leader.
  • Bumrungrad International Hospital in Thailand implements the InterSystems TrakCare EHR.
  • ChartLogic parent company MedSphere supports federal efforts to alleviate the opioid epidemic.

Blog Posts


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EPtalk by Dr. Jayne 11/1/18

November 1, 2018 Dr. Jayne No Comments

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November is Home Care & Hospice Month, so let’s give a shout-out to members of the healthcare informatics community who work in those environments. From my time at Big Health System, it seems like hospital projects get all the recognition and the lion’s share of the budget, while ancillaries like home health and hospice are struggling to even get support.

There are a number of challenges faced by these disciplines that make their work tricky – connectivity issues, mobile documentation, chart fragmentation, lack of coordination among prescribers and referring physicians, and more. Plus, there are the challenges inherent with going into people’s homes and dealing with unpredictable (and sometimes dangerous) situations.

Our occupational health clinic works with a home care group and I’ve heard stories about home care teams that go the extra mile bringing food and personal care items to patients who are struggling to stay out of the hospital. Hats off to these vital members of the healthcare team and the informatics personnel who support them.

Whether it’s related to the month of recognition or not, CMS released a rule finalizing changes to the Home Health Prospective Payment System. Claiming it will “strengthen and modernize Medicare,” it made changes to coverage for remote patient monitoring, added home infusion therapy benefits, and updated payments for home health with a new case-mix system. Burden is also supposed to be reduced through fewer reporting measures for certifying physicians. The changes begin in calendar year 2020.

Building on the legacy of EMRAM, HIMSS Analytics releases a new Infrastructure Adoption Model called INFRAM. Along with AMAM and CCMM, the models are designed to measure organizational efforts to improve processes and outcomes through technology implementation and adoption. INFRAM is designed to assess technical infrastructure within health systems, benchmarking prior to go live on EMR (as HIMSS still calls them) systems. Subdomains assessed as part of the model include security, collaboration, wireless capabilities, data center, and transport.

The American Medical Association is providing $15 million in grants over five years to fund innovations in residency training. The Reimagining Residency Initiative aims to transform residency training to better prepare graduates for the healthcare system of the future. Depending on the specialty, graduating residents are often unprepared to operate in the “non-system” that we have going in the US – they may not have been trained on value-based care, coding in such a way that one can actually be paid, and working collaboratively with other physicians and members of the healthcare team.

AMA did this previously in a $12 million program with medical schools, leading to development of a “Health Systems Science” textbook and curriculum to teach physicians to work with emerging technology and how to participate in patient safety, quality improvement, and team care projects. The Request for Proposal will be distributed on January 3, 2019 with letters of intent due February 1. Medical schools, health systems, and medical specialty societies are invited to participate along with graduate medical education sponsors. Awards will be announced in June 2019.

NCQA announces availability of various datasets to help us with our analytics endeavors. The Quality Compass 2018 dataset includes HEDIS and CAHPS data, aiding benchmarking. The current set includes data for commercial, Medicare, and Medicaid submissions. Separate data is also available for CAHPS 5 OH Adult survey results for commercial and Medicaid payers. Also, there is a CAHPS Booklet includes benchmark data for Adult and Child CAHPS surveys. Last, the Health Insurance Plan Ratings 2018-2019 results include scores similar to the Medicare Five-Star Quality Rating System.

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The American Medical Informatics Association announces its Inaugural Class of Fellows for the newly established FAMIA Applied Informatics Recognition Program. The program is designed “to recognize AMIA members who apply informatics skills and knowledge within their professional setting, who have demonstrated professional achievement and leadership, and who have contributed to the betterment of the organization.” The recognition is open to physicians, nurses, pharmacists, and others within clinical informatics. Formal recognition will occur at the AMIA 2019 Clinical Informatics Conference in Atlanta, April 30-May 2, 2019. Some of my favorite people are on the list – congratulations to all!

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As I’ve worked with youth in various community organizations over the last decade, I’ve seen the expansion of smartphones, with both positive and negative impacts on youth knowledge, exploration, and relationships. Time magazine reviews recent research on the impact of technology on young people’s mental health, noting increased rates of diagnosis for depression and anxiety in those using screen-based devices for more than seven hours per day. The data is from a 2016 study looking at more than 40,000 children ages 2 to 17.

When doing a sanity check on the data, I originally balked at the seven-hour figure as an outlier, but the study notes that around 20 percent of youth aged 14 to 17 spend this amount of time on screens each day. Youth in this use category were also more easily distracted, had emotional lability, and had difficulty finishing tasks compared to those who spent only an hour a day on screens. Adolescents were more likely to have issues than younger children.

Every time I’m in an airport and see toddlers and young children glued to a phone or tablet while their parents are also glued to a phone, I want to scream. Maybe I’m turning into the local curmudgeon, but childhood is a time for wonder and explanation. I want to tell them to take their children over to the window and look together at what is going on around the airplane. Watch the baggage handlers and look for your bags. See how the plane gets refueled. Talk about the jobs people do and how everyone plays a part in getting you to your vacation or grandma’s house or wherever.

Those behaviors in young childhood influence how individuals will use phones and devices as teens, and we know from numerous pieces of research that social media use is linked to low well being in teens and adolescents. There’s nothing funnier than watching a group of teens stand in a circle and “group chat” instead of actually chatting face-to-face with each other. Funny, but sad. I’m glad that one of the organizations I work with is a no-phone zone for the most part, forcing young people to interact with each other and also with the adults supporting their adventures.

Weird news of the day: Having one’s appendix removed has been linked to a nearly 20 percent lower risk of developing Parkinson’s disease. Researchers noted that the appendix holds alpha-synuclein, which is thought to influence Parkinson’s development. One working hypothesis is that the appendix participates in immune surveillance “contributes to Parkinson’s through inflammation and microbiome alterations.” It’s not compelling enough to run out and have surgery, but I’ll be interested to see where the data takes us.

What is your organization doing to celebrate Home Care & Hospice Month? Leave a comment or email me.

Email Dr. Jayne.

Morning Headlines 11/1/18

October 31, 2018 News 1 Comment

Athenahealth Is Near Deal With Veritas Capital, Elliott

Bloomberg reports that Elliott Management and Veritas Capital have teamed up to bid on Athenahealth.

DoD and VA Update: Early Results, Fine-tuning and Next Steps

Cerner Government Services President Travis Dalton updates stakeholders on the company’s DoD and VA software implementation efforts, noting it is “well positioned” for the DoD’s next phase at medical sites in California and Idaho.

HHS rolls out cyber center successor (to criticism)

Government officials cry foul over long-delayed HHS efforts to re-launch the fractious Healthcare Cybersecurity and Communications Integration Center as the Health Sector Cybersecurity Coordination Center.

Rhapsody Announces Completion of Acquisition by Hg, Launches as Independent Company Under New Leadership

Orion Health finalizes its sale of Rhapsody to Hg, enabling Rhapsody to launch as an independent company in Boston under the leadership of former McKesson executive Erkan Akyuz.

HIStalk Interviews Peter Butler, CEO, Hayes Management Consulting

October 31, 2018 Interviews No Comments

Peter Butler is president and CEO of Hayes Management Consulting of Wellesley, MA.

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Tell me about yourself and the company.

I’ve been at Hayes for 25 years. We are a technology-enabled company leveraging our MDaudit software platform to drive billing and audit compliance productivity as well as revenue integrity solutions across healthcare organizations.

Is it hard to retool a consulting firm into a software vendor?

It’s challenging. After a long corporate career in consulting, you develop a name for yourself in that area. We got our start with IT consulting, then over a period of time, moved into revenue cycle consulting and EHR implementations and so forth. Our MDaudit platform took a greater foothold in the industry and we were experiencing quite a lot of trust with it.

We saw this, years ago, as the future direction of the company. We foresaw health IT consulting needs diminishing and becoming commoditized. We wanted to leverage our strength. That’s when the software piece came in.

It was a difficult journey trying to change the mindset of a 25-year-old company and people who have a lot of longevity in it, asking them to think differently, more like a software company. It came with a lot of challenges.

Are you happy that you made that decision early when you see other consulting firms just now starting to react to market changes?

Very happy. When we were going through that transition, the hardest part was that it wasn’t happening fast enough. I look back in the rear-view mirror and say, OK, we did it. We got there. This is good. Where do we go from here? It’s important for us to stay relevant in the industry and in our client organizations.

We’ve turned the corner. We are looking forward to building ourselves as a software company and continuing to make a difference in healthcare.

What are the top issues in billing compliance?

Years ago, the top issue was how a healthcare organization with 2,000 providers could audit all of them annually. Then they acquire two more medical groups of a couple of hundred providers. How do they get through those audits with limited resources? Their organizations weren’t giving them the staff since they were really seen just a cost center.

Now the trend is, I have limited resources, so let me take a step back and look at all of the billing compliance risk areas to my organization. Bubble those to the surface so that I can take my limited resources and go tackle those challenges. Are they really risk areas that I should be concerned about, or are we a billing outlier for good reason because we are multi-specialty and we specialize in this type of service? In the old days, they were looking for fraud and abuse inside their organizations.

Now it’s taking a different turn. Where can I sharpen my attention to the revenue cycle? What am I actually providing for service, but not billing for? Compliance officers stay in the mindset of looking for areas where they can ensure that their organizations are billing appropriately, not over-billing Medicare things and like that. But they’re partnering with revenue integrity leaders inside their organization who are looking at the same data. What are we leaving on the table? We’ve delivered these services. There’s more pressure on reimbursement. We want to make sure we’re getting paid for everything we’ve done.

Is anybody doing a lot of billing compliance work as due diligence before provider acquisitions or mergers?

They are, but they should be doing more. I’ve had conversations with compliance officers who said, I just got a message from the CEO that we’ve signed our letter of intent. We’re moving forward with buying this practice or hospital. They aren’t paying attention to making sure that, as part of the due diligence process, they are billing and coding appropriately. Let’s understand the risks of acquiring this organization. It’s almost been an afterthought from senior leadership that the compliance professionals find themselves in post-transaction.

Is the focus different when a private equity firm is the buyer, such as the trend of acquiring dermatology practices?

We’ve had some of those PE-backed companies call us and say, we’re about to make an offer for this dermatology practice. Before we finalize it, can you do some diligence around their revenue cycle and their billing practices? Make sure that they are billing and coding appropriately and that what they are telling us and what we’re reading in the reports is actually what’s happening.

Those are mini-assessments. They don’t take a lot of time, but they give the buyer an opportunity to understand where the risks and opportunities are. Once they finalize the deal, if they go forward, where can they find revenue opportunity and operational efficiency? There’s definitely a lot of that from the financially-minded buyers.

What trends are you seeing that aren’t getting much attention?

A lot of revenue cycle leaders in years past ran their organizations based on metrics. They would tell their staff, you need to make X number of calls or you need to touch X number of claims. A trend I’m seeing that will pay dividends later is that instead of looking at volume-based metrics or metrics for the sake of metrics inside those revenue cycle follow-up departments or patient access departments, ask that if you touched a claim, what did you do with it? Did you make changes to it that positively affected the organization? Were you able to identify root cause and go back and make changes that actually stuck so that we’re not seeing these problems over and over?

Some of our clients are assigning audit-minded people to look at the goals and responsibilities of those who support the day-to-day operations. Looking at whether their daily tasks drive positive change, the quality outcome in the operation. They are using spreadsheets to document who they’re working with, the types of audit completed, the follow-up, and the result.

It can become an arduous task, but the concept is, are you driving better quality outcomes in your role, or are you just saying you made your 50 calls or worked your 10 work queues? What was the result of that? That’s an important trend and overdue in healthcare.

Hopefully we can instill some best practices in the industry so that we have less need for those auditors. You’ve done your training and you’ve built some great training programs to educate the people who are touching every aspect of the business operation.

Do you have any final thoughts?

Some interesting things are happening that we’ll see more of as quality reimbursement plays a bigger role in healthcare. CMS recently proposed some E&M simplification rules with the concept that it will save money and provider coding time. They’ll save 50 hours a year or something like that, taking away all of the detail-level E&M coding and documentation you have to do. CMS is also looking for ways to save money for the taxpayers and the government, so it has to be viewed through that lens as well.

It will come at some point, probably not in January, but it will come with challenges that the healthcare industry needs to walk through. If you’re billing Medicare, you’ve got Blue Cross Blue Shield as secondary, and you’re doing simplified billing for Medicare, what do you do with that claim? It gets passed down to a secondary payer. There are other issues around RVUs and how you reimburse your doctors that will be impacted by changes like this from CMS. We have a lot of work to do as we think about simplifying the billing process in the industry. It won’t come without challenges.

A Machine Learning Primer for Clinicians–Part 3

Alexander Scarlat, MD is a physician and data scientist, board-certified in anesthesiology with a degree in computer sciences. He has a keen interest in machine learning applications in healthcare. He welcomes feedback on this series at drscarlat@gmail.com.

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Previous articles:

  1. An Introduction to Machine Learning
  2. Supervised Learning

Unsupervised Learning

In the previous article, we defined unsupervised machine learning as the type of algorithm used to draw inferences from input data without having a clue about the output expected. There are no labels such as patient outcome, diagnosis, LOS, etc. to provide a feedback mechanism during the model training process.

In this article, I’ll focus on the two most common models of unsupervised learning: clustering and anomaly detection.

Unsupervised Clustering

Note: do not confuse this with with classification, which is a supervised learning model introduced in the last article.

As a motivating factor, consider the following image from Wikipedia:

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The above is a heat map that details the influence of a set of parameters on the expression (production) of a set of genes. Red means increased expression and green means reduced expression. A clustering model has organized the information in a heat map plus the hierarchical clustering on top and on the right sides of the diagram above. 

There are two types of clustering models:

  • Models that need to be told a priori the number of groups / clusters we’re looking for
  • Models that will find the optimal number of clusters

Consider a simple dataset:

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Problem definition:

  • Task: identify the four clusters in Dataset1.
  • Input: sets of X and Y and the number of groups (four in the above example).
  • Performance metric: total sum of the squared distances of each point in a cluster from its centroid (the center of the cluster) location.

The model initializes four centroids, usually at a random location. The centroids are then moved according to a cost function that the model tries to minimize at each iteration. The cost function is the total sum of the squared distance of each point in the cluster from its centroid. The process is repeated iteratively until there is little or no improvement in the cost function.

In the animation below you can see how the centroids – white X’s – are moving towards the centers of their clusters in parallel to the decreasing cost function on the right.

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While doing great on Dataset1, the same model fails miserably on Dataset2, so pick your clustering ML model wisely by exposing the model to diverse experiences / datasets:

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Clustering models that don’t need to know a priori the number of centroids (groups) will have the following problem definition:

  • Task: identify the clusters in Dataset1 with the lowest cost function.
  • Input: sets of X and Y (there are NO number of groups / centroids).
  • Performance metric: same as above.

The model below initializes randomly many centroids and then works through an algorithm that tells it how to consolidate together other neighboring centroids to reduce the number of groups to the overall lowest cost function.

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From “Clustering with SciKit” by David Sheehan

3D Clustering

While the above example had as input two dimensions (features) X and Y, the following gene expression in a population has three dimensions: X, Y, and Z. The mission definition for such a clustering ML model is the same as above, except the input has now three features: X, Y, and Z.

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The animated graphic is at www.arthrogenica.com

Unsupervised Anomaly Detection

As a motivating factor, consider the new criteria for early identification of patients at risk for sepsis or septic shock, qSOFA 2018. The three main rules:

  • Glasgow Coma Scale (GCS) < 15
  • Respiratory rate (RR) >= 22
  • Systolic blood pressure (BP) <=100 mmHg

Let’s focus on two parameters, RR and BP, and a patient who presents with:

  • RR = 21
  • BP = 102

A rule-based engine with only two rules will miss this patient, as it doesn’t sound the alarm per the above qSOFA definition. Not if the rule was written with AND and not it had OR between the conditions. Can a ML model do better? Would you define the above two parameters, when taken together, as an anomaly ? 

Before I explain how a machine can detect anomalies unsupervised by humans, a quick reminder from Gauss (born 1777) about his eponymous distribution.

One-Variable Gaussian Distribution

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You may remember from statistics that the above bell-shaped normal Gaussian distribution can accurately describe many phenomena around us. The mean on the above X axis is zero and then there are several standard deviations around the mean (from -3 to +3). The Y axis defines the probability of X. Each point on the chart has a probability of occurrence: the red dot on the right can be defined as an anomaly with a probability of ~ 1 percent. The dot on the left side has a probability of ~ 18 percent,  so most probably it’s not an anomaly. 

The sum (integral) of a Gaussian probability distribution is one, or 100 percent. Thus even an event right on top of our chart has a probability of only 40 percent. Given a point on the X axis and using the Gaussian distribution, we can easily predict the probability of that event happening.

Two-Variable Gaussian Distribution

Back to the patient that exhibits RR = 21 and BP=102 and the decision whether this patient is in for a septic shock adventure or not. There are two variables: X and Y, and a new problem definition:

  • Task: automatically identify instances as anomalies if they are beyond a given threshold. Let’s set the anomaly threshold at three percent.
  • Input: sets of X and Y and the threshold to be considered an anomaly (three percent).
  • Performance metric: number of correct vs. incorrect classifications with a test set, with known anomalies (more about unbalanced classes in next articles).

The following 3D peaks chart has X (RR), Y (BP), and the Gaussian probability as Z axis. Each point on the X-Y plane has a probability associated with it on the Z axis. Usually a peaks chart has an accompanying contour map  in which the 3D is flattened to 2D, with the color still expressing the probability.

Note the elongated, oblong shape of both the peaks chart and the contour map underneath it. This is the crucial fact: the shape of the Gaussian distribution of X and Y  is not a circle (which we may have naively assumed), it’s elliptical. On the peaks chart, there is a red dot with its corresponding red dot on the contour map below. The elliptic shape of our probability distribution of X and Y helps visualizing the following:

  • Each parameter, when considered separately on its own probability distribution, is within its normal limits.
  • Both parameters, when taken together, are definitely abnormal, an anomaly with a probability of ~ 0.8 percent (0.008 on the Z axis), much smaller than the three percent threshold wee set above.

image

Unsupervised anomaly detection should be considered when:

  • The number of normal instances is much larger than the number of anomalies. We just don’t have enough samples of labeled anomalies to use with a supervised model.
  • There may be unforeseen instances and combinations of parameters that when considered together are abnormal. Remember that a supervised model cannot predict or detect instances never seen during training. Unsupervised anomaly detection models can deal with the unforeseen circumstances by using a function from the 1800s.

Scale the above two-parameter model to one that considers hundreds to thousands of patient parameters, together and at the same time, and you have an unsupervised anomaly detection ML model to prevent patients deterioration while being monitored in a clinical environment. 

The fascinating part about ML algorithms is that we can easily scale a model to thousands of dimensions while having, at the same time, a severe human limitation to visualize more than 5D (see previous article on how a 4D / 5D problem may look).

Next Article

How to Properly Feed Data to a ML Model

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